CBT for Appearance Anxiety Psychosocial Interventions for Anxiety due to Visible Difference

by Clarke, Alex; Thompson, Andrew R.; Jenkinson, Elizabeth; Rumsey, Nichola; Newell, Robert

• ISBN13: 9781118523421
• ISBN10: 1118523423
• Edition: 1st
• Format: Paperback
• Copyright: 2013-12-16
• Publisher: Wiley-Blackwell

Summary

This clinical manual provides a CBT-based psychosocial intervention for use with individuals distressed about their appearance due to a disfigurement from birth, accident or illness, or those coping with another visible difference.

 

• Contains a wealth of case material with specific relevance to physical health conditions that affect appearance, practical advice on assessment, and session-by-session guidance for addressing common issues
• Written by leading academics and clinicians working in the management of disfigurement and rational appearance anxiety
• Uses a flexible stepped-care model that allows for use by experienced CBT practitioners as well those wishing to deliver a more basic psychological intervention
• Identifies the psychological factors involved in appearance anxiety while also addressing the practical concerns of living with a visible difference, such as managing the reactions of others

Author Biography

Alex Clarke is a clinical and health psychologist specializing in disfigurement and altered appearance.

Andrew R. Thompson is Reader in Clinical Psychology at the University of Sheffield NHS Clinical Psychology Doctoral Training Programme.

Elizabeth Jenkinson is a registered Practitioner Health Psychologist, Chartered Psychologist and Senior Lecturer in Health Psychology at the University of the West of England.

Nichola Rumsey is Vocational Training Charitable TrustProfessor of Appearance Research at University of the West of England and is Co-Director of the Centre for Appearance Research.

Rob Newell is Emeritus Professor of Nursing Research at the University of Bradford.

Table of Contents

Foreword xv

Preface xvi

1 Background, Clinical Problems, Common Presentation and Treatment Considerations 1

Physical and Treatment-Related Factors 3

Socio-Cultural Factors 3

Psychological Factors and Processes 3

Body Image Disturbance 3

Clinical Problems and Presentation 4

Common Features in Referral 8

Visibility of Condition 8

Shame 9

The Meaning of Visible Difference 9

The Experience of Loss 9

Physiological Responses 10

Culture 10

Gender 11

Age 11

Expectations of Treatment 11

Association of Physical Change with Psychological Outcome 12

Fix It Solutions 12

Treatment Considerations 13

2 A Stepped-Care Approach to Psychosocial Intervention 15

The PLISSIT Model 16

Level 1: Permission 16

Level 2: Limited Information 18

Level 3: Specific Suggestions 18

Level 4: Intensive Treatment 19

3 Models and Frameworks: Expanding the Conceptual Approach to Managing Appearance-Related Distress 21

Explanation for Choice of Therapeutic Approach 22

Behavioural Approaches: Fear Avoidance and Social Skills Training 22

Building an Evidence Base 25

Cognitive Approaches: Comparison of Appearance Anxiety and Social Phobia 26

Use of Safety Behaviours 28

Anticipatory and Post-Event Processing 29

The Role of Assumptions and Schema in Appearance Anxiety 32

Summary 33

Deriving a Cognitive Behavioural Treatment Model: Identifying Factors and Processes

Contributing to Successful Adjustment to Disfiguring Conditions 34

Working Framework of Adjustment to Disfiguring Conditions 34

The ARC Framework of Adjustment to Disfiguring Conditions 34

Predisposing Factors 35

Intervening Cognitive Processing 36

Socio-Cognitive Processing 37

Outcomes 41

The ARC Research Programme Findings 43

The Studies 43

Summary of Findings 43

Key Messages from the Research Programme 45

Implication of These Findings for Design of Interventions 45

Summary 47

4 Clinical Assessment 48

Eliciting the Problem 49

Summarizing 51

Motivation and Self-Efficacy 52

Readiness for Change 53

Measurement Tools 55

Generic Measures of Psychological Constructs (as used in the ARC Study) 55

Measures of Psychological Constructs Specifically Related to Appearance 57

Measures of Body Image 58

Measures of Psychological Constructs Specifically Related to a Condition Type 58

Body Dysmorphic Disorder (BDD) 59

Core Clinical Dataset 59

Regular Subjective Measures of Frequency for Events, Thoughts and Feelings 60

Goal Setting 61

The SMART Acronym 61

Challenges in Treatment for Appearance-Related Problems 62

Introducing a Biopsychosocial Model 62

Treatment ‘buy-in’ 63

5 Social Skills and Coping Strategies 64

Staring, Questions, Comments and Loss of Anonymity 66

Making the Most of Appearance 66

Developing a Positive Approach to Visible Difference 67

Posture, Smiling and Eye Contact 67

Developing Verbal Skills 68

Learning to Have a Conversation 68

Answering Questions About Appearance 68

Managing Staring 70

Putting it into Practice 71

Taking the Initiative in Social Encounters 72

Managing Anger and Developing Assertiveness 73

Anger 73

Managing Intimacy 75

Disclosing a Disfiguring Condition to a Partner 75

Summary 77

6 Cognitive Behavioural Therapy 78

Techniques in Cognitive Behavioural Therapy 79

Socratic Dialogue 79

Eliciting Negative Automatic Thoughts 82

Unhelpful Beliefs Record Form 84

Negative Automatic Thinking Styles Associated with Anxiety 84

Triple Column Technique 87

Pie Charts 87

Manipulating Safety Behaviours 88

Anxiety management techniques 88

Target, Tools, Troubleshoot, Test 89

Cost–Benefit Analyses 90

Some Techniques for Dealing with Appearance-Related Self-Criticism and Shame 93

Functional Analysis of Self-Criticism 94

Identifying the power of self-criticism 94

Summary 97

7 Planning Treatment and Sessional Guides 98

Introduction 102

Working at Level 1 102

Working at Level 2 104

Working at Level 3 105

Session 1 106

Structure Outline 106

Working at Level 3 Using FaceIT (www.faceitonline.org.uk) 108

Working at Level 4 using CBT 108

Planning Treatment and Sessional Guides 108

Clinical Examples 112

Example 7.4 112

Session 1 112

Session 2 116

Review Data 116

Set Agenda 116

Restatement of Formulation 117

Elicit Patient Understanding 118

Session 3 118

Review of Homework and Reformulation 118

Set Agenda 119

Introduction to Answering Questions About Her Face 119

Role of Self-Focused Attention Discussed 119

TTTT 119

Homework 119

Session 4 119

Review of Homework and Reformulation 119

Set Agenda 120

Reattribution of Beliefs 120

Design Behavioural Experiments 121

Homework 121

Session 5 121

Review of Homework 121

Set Agenda 121

Strategies for Attentional Training 122

Development of Personal Coping Approaches 122

Homework 122

Session 6 122

Review of Homework 122

Measure Noticeability and Worry 122

Reattribution of Beliefs 122

Feedback from Behavioural Experiments 122

Development of Personal Coping Approaches 123

Homework 123

Session 7 123

Review of Homework 123

Set Agenda 123

Schema-Focused Reattribution 123

Preparation for Ending 123

Homework 123

Session 8 124

Review of Homework 124

Schema-Focused Reattribution 124

Planning for Ending 124

Homework 124

Session 9 124

Homework 124

Agenda 124

Outcome 125

Example 7.5 126

Session 1 126

Summary 129

Session 2 130

Review Data 130

Introduction to Social Comparison Processes 130

Restatement of Formulation 130

Elicit Patient Understanding 131

Introduction to Compassionate Thinking 132

Homework 132

Session 3 132

Review of Homework and Reformulation 132

Set Agenda 132

TTTT 132

Introduction to NATs 132

Section 4 133

Review of Homework and Reformulation 134

Set Agenda 134

Reattribution of Beliefs 136

Design Behavioural Experiments 136

Session 5 137

Review of Homework and Reformulation 137

Set Agenda 137

Session 6 137

Review of Homework and Reformulation 137

Set Agenda and Review Progress 138

Measure Noticeability and Worry 138

Reattribution of Beliefs 138

Feedback from Behavioural Experiments (Disclosure) 138

Homework 138

Sessions 7, 8 and 9 138

Review of Homework and Development of Final Reformulation (See Figure 7.13) 138

Set Agenda 139

Focus on Schema-Focused Reattribution 139

Session 10 140

Outcome 140

Example 7.6 140

Session 1 140

Summary 144

Session 2 144

Review Data 144

Noticeability and Worry Graph 145

Set Agenda 145

Introduction to Social Comparison Processes 146

Self-Efficacy 146

Safety Behaviours 146

Restatement of Formulation 146

Homework 147

Session 3 147

Review of Homework and Reformulation 147

Set Agenda 147

TTTT 147

Anxiety Management 148

Introduction to NATs 148

Homework 148

Session 4 148

Review of Homework and Reformulation 148

Set Agenda 148

Design Behavioural Experiments 149

Homework 149

Session 5 149

Review of Homework 149

Set Agenda 149

Homework 149

Session 6 150

Review of Homework 150

Set Agenda 150

Measure Noticeability and Worry 150

Design of Behavioural Experiments 151

TTTT: Role Play Her Response If Her Breasts Are Mentioned 151

Homework 151

Session 7 151

Review of Homework 151

Set Agenda 151

Focus on Reattribution 151

Preparation for Ending 152

Homework 152

Sessions 8, 9 and 10 152

Session 11 152

Homework 154

Agenda 154

Outcome 154

Example 7.7 154

Session 1 154

Summary 157

Session 2 157

Review Data 157

Plan Homework 158

Therapeutic Buddy 158

Homework 158

Session 3 158

Review of Homework and Reformulation 158

Homework 159

Session 4 160

Review of Homework and Reformulation 160

Set Agenda 160

Set Homework 160

Session 5 160

Review of Homework 160

Set Agenda 160

Homework 161

Session 6 161

Review of Homework and Reformulation 161

Set Agenda 161

Completion of Rating Scales and Outcomes 161

Sessions 7 and 8 161

Set Agenda 161

Session 9 162

Completion of Rating Scales and Outcomes 162

Summary and Feedback 162

Outcome 162

Long-Term Outcome and Maintenance of Change 162

Complete Maintenance 162

Partial Maintenance 163

Slip-Back and Sub-maintenance 163

Slip-Back and Failure 163

Social Support and Therapeutic Partners 164

Summary 164

Additional Resources 165

8 The Emerging Adult: Facilitating Transition from Child to Adult Service 166

Introduction 167

Introducing the Problem of Transition 167

Transition from the Young Person’s Perspective 168

Transition from the Parents’ Perspective 168

Transition from the Health Professionals’ Perspective 168

Guidance for Improving Transitional Care 169

Issues Pertinent to Caring for Young People with Appearance Concerns 170

The Salience of Appearance to Young People 170

Reluctance to Seek or Accept Support 171

Factors that Can Promote Adjustment to a Visible Difference among Young People 171

Romantic Issues 173

Transition as an Opportunity for Those with a Visible Difference 174

Concluding Remarks 175

9 Psychological Assessment for Cosmetic Surgery 176

Introduction 177

Is Cosmetic Surgery Effective? 177

Access to Surgery in the NHS 178

Psychological Screening by the Surgeon 179

NICE Guidelines 179

Onward Referral 179

What Does the Surgeon Want from a Psychological Assessment? 180

What Does the Patient Want from a Psychological Assessment? 181

A Framework for Psychological Assessment 181

Case Examples 183

Common Problems in Referral 189

Liaising with the GP 189

Health Professionals’ Knowledge of Cosmetic Procedures 189

Summary 190

Additional Resources 190

10 Models of Service Delivery 191

Lay-Led Support 192

Specialist Services 192

Outlook 192

Embedded Services 192

Royal Free Hospital, London 192

Access to Psychology Services 192

Access to Mental Health Services 193

Mapping Service Models onto Stepped Care 193

Appendix 194

Resources 272

References 280

Index 293